Immediate Management of Suspected Stroke with Facial Drooping
Activate emergency medical services (EMS) immediately and transport the patient to a designated stroke center with advanced imaging and thrombolytic therapy capabilities. 1, 2
Immediate Recognition and EMS Activation
Use the FAST (Face, Arms, Speech, Time) assessment to confirm stroke signs: examine for facial droop, arm weakness, and speech disturbance—these three physical examination items are validated for layperson stroke recognition and show good agreement with physician assessment (kappa values 0.49-0.77). 1, 3
Do not delay EMS activation for any reason—stroke is a time-sensitive emergency where early intervention is most effective, and EMS use is associated with earlier ED arrival, quicker evaluation, more rapid treatment, and better outcomes. 1
Measure capillary blood glucose if immediately available and does not delay EMS activation, as hypoglycemia can mimic stroke symptoms. 1
Critical Time-Dependent Treatment Window
The patient must reach the emergency department within 4.5 hours of symptom onset to be eligible for intravenous tissue plasminogen activator (tPA), which is the evidence-based therapy that improves long-term functional outcomes in acute ischemic stroke. 1, 2
The risk of recurrent stroke is highest in the first 48 hours after symptom onset, making immediate evaluation absolutely critical. 4
Essential Emergency Department Evaluation Sequence
The stroke center should perform these evaluations in parallel, not sequentially:
Brain MRI with diffusion-weighted imaging is the preferred initial imaging to detect acute ischemic changes and differentiate ischemic from hemorrhagic stroke, which fundamentally changes treatment. 2
If MRI is unavailable, perform CT head without contrast immediately to rule out hemorrhage before considering thrombolytic therapy. 1, 2
CT angiography or MR angiography from aortic arch to vertex must be completed within 24 hours to evaluate for vascular occlusion and stenosis. 4, 2
12-lead ECG without delay to evaluate for atrial fibrillation or other cardiac sources of embolism. 4
Immediate ophthalmological examination in parallel with neurological assessment (National Institutes of Health Stroke Scale calculation) if any visual symptoms are present. 1
Thrombolytic Treatment Protocol
If ischemic stroke is confirmed on imaging and the patient presents within 4.5 hours with no contraindications, administer intravenous alteplase at 0.9 mg/kg (10% given over 1 minute, remainder over 59 minutes). 1, 2
Before tPA administration, obtain platelet count and coagulation studies (PT/INR and aPTT) if there is high suspicion for coagulopathy. 1
Critical Pitfalls to Avoid
Do not dismiss facial drooping as Bell's palsy without ruling out stroke—Bell's palsy is a peripheral facial nerve disorder that does not cause other neurological deficits, whereas stroke can present with multiple cranial nerve or motor findings. 2, 5
Do not delay imaging to obtain outpatient evaluation or institute other treatments—immediate triage to the emergency department is mandatory, and any delay reduces the likelihood of receiving time-sensitive interventions. 1, 2
Do not rely on normal CT without contrast to exclude stroke—MRI with diffusion-weighted imaging is far more sensitive for acute ischemic changes, particularly in posterior circulation strokes. 2
Do not assume symptoms will resolve spontaneously—even transient symptoms (TIA) carry a 10% risk of completed stroke within the first week and require the same urgent evaluation. 4
Post-Acute Management Considerations
If symptomatic vertebrobasilar stenosis is identified, initiate dual antiplatelet therapy for the first 21 days in patients not undergoing revascularization, followed by long-term single antiplatelet therapy. 2
Refer for possible carotid revascularization if extracranial carotid stenosis is identified on vascular imaging. 4
Implement eye protection immediately if eye closure is impaired due to associated facial weakness to prevent corneal exposure. 2